BRAIN ATTACK

1. BRAIN ATTACK UNDERSTANDING AND MANAGING ACUTE STROKE Carolyn Walker RN, BN. January 2011

2. Brain Attack: Understanding and Managing Acute Stroke Learning Objectives: Upon completion of this session, participants will be able to: • Describe the 2 major types of stroke • Identify the location of stroke given stroke symptoms • Describe the management of hypertension in acute stroke • Explain the appropriate management of acute ischemic stroke

3. Epidemiology of Stroke: The Canadian Perspective • 50,000 new stroke patients/year in Canada† • 5,500 Albertans suffer a stroke each year • Every 10 minutes someone in Canada suffers a “brain attack” • 3rd leading cause of death in Canada • The leading cause of adult disability • 200,000–300,000 stroke survivors† • Cost to society: $300-400 million/yr Alberta • 28% of stroke patients are under age 65* †Statistics Canada

4. What is a stroke? BLOCKAGEBREAKAGE blood vessel occlusion or blood vessel rupture (clot / atherosclerosis) sudden interruption in cerebral blood flow brain injury to affected area brain death of affected area

5. Stroke: Brain Attack • Stroke is a “brain attack” • Stroke is an EMERGENCY!

6. Frequency of Stroke by Type • Ischemic (85%) Thrombotic (54%), Embolic (31%) • Ischemic Stroke – 65% • TIA – 20% • symptoms resolve • no brain cell death • 20-40% of strokes are proceeded by TIA • Hemorrhagic (15%) • Intracerebral – 10% • Subarachnoid – 5% Blockage Breakage

7. The Brain • Cerebrum • Diencephalon • Cerebellum • Brainstem

8. Cerebrum • Center for highest function • Governs thought, memory, reasoning, sensation and voluntary movement • Divided into two hemispheres • Left Hemisphere • dominant in 95% of people • Right Hemisphere

9. Functions of Cerebral Hemispheres PHOTO: Courtesy of National Stroke Association

10. Cerebellum

11. Motor and Sensory Function PHOTO: Courtesy of National Stroke Association

13. Cerebrum • Basal ganglia • Bands of grey matter deep within the cerebral hemispheres • Control automatic associated movements • i.e. arm swing alternating with leg movement • posture

14. Diencephalon • Includes thalamus and hypothalamus • Extends from cerebrum to midbrain • Surrounds 3rd ventricle • Thalamus • Receives sensory input • Relay station to cerebral cortex • Hypothalamus • Major control centre • Regulation of temp, H2O balance, sleep, behavior • Coordinator of autonomic nervous system activity

15. Cerebellum • Located under occipital lobe • Unconscious motor coordination of voluntary movement • i.e. complex coordination of different muscles needed to juggle, swim, etc. • Equilibrium • Muscle tone

16. Brain Stem • Central core of brain • Consists mostly of nerve fibers • Midbrain • Auditory/visual systems • Pons • Respiratory centers • Medulla • Respiratory and vasomotor control

17. Blood Supply to the Brain PHOTO: Courtesy of National Stroke Association

18. Blood Supply to the Brain

19. Blood Supply to the Brain 90% of all strokes • Carotid Arteries & Branches: anterior 2/3 cerebral of hemispheres • Vertebral Arteries & Branches: posterior and medial regions of hemispheres brainstem diencephalon (thalamus/hypothalamus) cerebellum Courtesy Genentech 10% of all strokes

20. Hemorrhagic Stroke Intracerebral Hemorrhage Subarachnoid hemorrhage

21. Intracerebral Hemorrhage • Result of ruptured Blood vessel • Hypertension most common cause • Usual Presentation: • Headache • Hemiplegia • Decreased level of consciousness • Nausea & Vomiting

22. Subarachnoid Hemorrhage • Blood vessel ruptures & bleeds into subarachnoid space (Aneurysms/arteriovenous malformations ) • “Worst headache of one’s life” • Nausea & vomiting • Neck stiffness • Neurologic signs don’t fit pattern of a single blood vessel • Varying level of consciousness

23. Management of SAH and ICH:The First Few Hours • Correct airway, breathing or circulation • Treat severe elevation of BP • Obtain neurosurgical consult • Treat elevated intracranial pressure • Admin anticonvulsant therapy if seizures

24. Intracerebral Hemorrhage: Hypertension Management Recommendations: Maintain SBP < 180 mmHg and DBP < 100 mmHg • MAP < 130 mmHg if history of hypertension DO NOT REDUCE BP BY MORE THAN 20% CONTACT STROKE SPECIALIST AT COMPREHENSIVE STROKE CENTER!

26. Ischemic Stroke - The Problem

27. Etiology of Ischemic Stroke Graphics courtesy Boehringer Ingelheim

28. Classifications of Ischemic Stroke • Small vessel disease • Lacunar infarction • Large vessel disease • Artery to artery emboli (large artery atherosclerosis) • Cardioembolic • Cryptogenic (Don’t know the Cause) • Other (Cocaine, coagulopathies)

29. Progression of Ischemic Stroke Graphics courtesy Boehringer Ingelheim

30. TIME IS BRAIN!In a typical large vessel acute ischemic stroke…- 1.9 million neurons - 14 billion synapses - 12 km of myelinatedfibersare destroyed each minute …(JL Saver, 2006)

31. Symptoms of “Brain Attack” Speech Strength Sight

33. ACUTE STROKE OUTCOMES CAN BE IMPROVED IF WE PROVIDE ARAPID COORDINATED RESPONSE!

34. Approaches to Acute Therapy • Neuroprotection • Studies* • Reperfusion

35. REPERFUSION - Thrombolytic Agents • Intravenous rt-PA • Strict protocols for use with ischemic stroke • Improves outcomes compared to the risk of serious bleeding

36. Canadian Stroke Strategy:Best Practice Recommendations 2010 • All patients with disabling acute ischemic stroke who can be treated within 4.5 hours after symptom onset should be evaluated without delay to determine their eligibility for treatment with t-PA.

37. Diminishing Returns over Time Favorable Outcome (mRS 0-1, BI 95-100, NIHH 0-1) at Day 90 Adjusted odds ratio with 95% confidence interval by stroke onset to treatment time (OTT) ITT population (N=2776) Pooled Analysis NINDS tPA, ATLANTIS, ECASS-I, ECASS-II Courtesy Brott T et al

38. REPERFUSION • Intra-arterial lytic • ultrasonic clot-busting

39. REPERFUSION: Devices - Clot Retrieval Mechanical Thrombectomy Devices • MERCI study: MERCI device Mechanical Embolus Removal in Cerebral Ischemia • Penumbra device

40. Canadian Stroke Strategy:Best Practice Recommendations 2010 There remain situations where there are sparse or little clinical trial data to support the use of thrombolytic therapy: • Paediatric stroke • Over 80 years with diabetes • Present within time window but do not meet current criteria for treatment with IV t-PA • Intra-arterial thrombolysis Treat based on clinical decision of physician and family

41. EMS Protocol- Arrival at scene PRIORITY IS LOAD AND GO ABC’s first Determine time last known to be normal Acute Stroke Screen Perform directed neurological assessment Blockage or Breakage?

42. Onset Time • Onset Time = Time when patient was last seen well • Requires detective skills

43. Pre-Hospital Care:Direct transport to Primary Stroke Centre (PSC) • A standardized acute stroke diagnostic screening tool should be used by paramedics • Pts with symptoms of stroke should be transported without delay to the closest institution that provides emergency stroke care • Direct transport protocols must be in place • Paramedics must notify the receiving facility • Transfer care to receiving facility without delay (scene time < 10 min) EMS Stroke Screening Form

44. 0 10 20 30 40 50 60 70 80 90 minutes

45. vs CT scanner 40 miles 8 miles Local hospital No CT scanner intraclot lysis ICH evacuation vs 70 miles Early ICA revascularization 170 miles Interventional Facilities- interventional neurorad, neurosurgery Comprehensive Stroke Center vs Helical or multislice CT scanner 24h/365d coverage Primary Stroke Center

46. Alberta Stroke Centre Locations • Primary Stroke Centre (PSC): 14 • CT scan availability • Door to CT < 20 min. with a pre-alert • Stroke expertise on-site or available by Telestroke link • r-tPA treatment availability • May not be available 24/7 • Comprehensive Stroke Centre (CSC): 3 • CT scan availability • Door to CT < 20 minutes with a pre-alert • Stroke team on-site • Neurological expertise on-site • Neurointerventional expertise on-site • Central hub of stroke Neurologist expertise in a telestroke network

47. Initial Management of Stroke:A. Immediate General Assessment • Assess A B C’s, vital signs (BP, HR, Temp***) • Provide oxygen (O2 sats >95%, if COPD >90%) • Start an IV Line (large bore)- no dextrose • 12 Lead ECG / cardiac monitoring • Obtain blood samples (CBC, lytes, Cr, gluc, PTT, INR) • Check Blood Sugar Levels*** • Perform general neurological screening • Alert Stroke Team

48. Canadian Stroke Strategy:Best Practice Recommendations 2010 • Monitoring in the acute phase should include • HR and rhythm, BP, temp, O2 sat, hydration, swallowing ability and presence of seizure activity • Initial blood work should include • CBC, lytes, Cr, urea, glucose, INR, PTT, TSH, fasting lipids, CK and troponin • Neurovascular Imaging – should undergo brain imaging (MRI or CT) immediately • Vascular imaging of the brain and neck arteries ASAP • Cardiovascular investigations • After initial ECG-daily ECG’s x 72 hrs • May also monitor x 72 hrs to detect afib • Echocardiography if suspect embolic stroke

49. Canadian Stroke Strategy:Best Practice Recommendations 2010 • Acute Aspirin Therapy • All stroke pts not on antiplatelet therapy should be given at least 160 mg of ASA immediately as a one time loading dose after brain imaging excludes hemorrhage • If treated with t_PA- delay ASA until after 24 hour CT excluding hemorrhage • If taking ASA may consider plavix

50. Hypertension During Acute Stroke • Systolic BP > 160mmHg is seen in over 60% stroke patients (Robinson et al, Cerebrovasc Dis., 1997) • Often transient, lasting 24-72 hours and in most patients does not require treatment. • Little evidence and no benefit seen for rapid lowering of BP in acute stroke without rt-PA